Penicillin allergy is very challenging for CIED clinicians when managing both prophylaxis and/or treatment of infections. Drs. Callahan and Wilkoff are joined by Dr. Paul Pottinger, Professor of Infectious Disease at the University of Washington in Seattle, to discuss penicillin allergy – how to tell if a patient has a true allergy as well as patient management.
Join the discussion! How do you manage antibiotic drug allergies?
Podcast Transcript: Episode 9 – Management of Penicillin Allergy and CIED Procedures
Dr. Tom Callahan
Hello, welcome to LEADconnection.org podcast, where we talk about all things related to lead management. I’m Tom Callahan. I’m joined by Dr. Bruce Wilkoff and Dr. Paul Pottinger
Do you two want to take a moment to introduce yourself?
Dr. Bruce Wilkoff
Sure. I’ve been overseeing lead related things for a long time at the Cleveland Clinic, and I hope you all know who I am, but Paul’s a man that I met at another conference and I think he has a perspective that we’ll all enjoy.
Paul, do you want to explain where you’re from and, and what you do in general?
Dr. Paul Pottinger
Well, first of all, I’m not an electrophysiologist, I am a friendly infectious disease doctor. I’m Paul Pottinger, Professor of ID at the University of Washington in Seattle. I take care of patients who have concerns around general infections, and that does include infected devices, both endovascular pocket infections, the whole gamut. So I am happy to talk about that topic.
Dr. Bruce Wilkoff
And Paul’s come all the way from Seattle here to Cleveland to join us for this. And I’m really excited about this because we need to look at things at different perspectives and we have some great ID support here, but getting new information and maybe looking at things a little differently is important.
What do you have to start us off with Tom?
Dr. Tom Callahan
Well, we are pleased to be joined by one of our infectious disease colleagues. So let’s dive into infectious disease issues. So, I think one thing that is a burning question for a lot of people. One thing that comes up often is the question of antibiotic allergies, drug allergies, penicillin allergy in particular, and sort of how to navigate that issue in patients either for prophylaxis or treatment.
Dr. Paul Pottinger
I appreciate that question so much. What we know about prophylaxis is that you want to target the germ that’s likely to cause the infection. And so one of the important workhorses in general, not only in EP but I think in electrophysiology and device infection prevention, really is around getting a cephalosporin into those patients.
Cefazolin is a first generation cephalosporin. Some people call it cefazolin. I call it cefazolin. PoTAYtoh. PoTAHto. This is your first generation cephalosporin and it’s a great drug because it’s quick, it’s clean, it can go in very rapidly, and it also targets some of those big bugs that you’re worried about in this situation. That’s methicillin sensitive staph aureus (MSSA) and Cutibacterium acnes. It covers a lot of gram-negative infections as well.
Currently, people are worried about using this in the lab because about 10% of Americans are labeled with a penicillin allergy. I’m not going to say that they’re allergic because of those 10% who believe they’re allergic, 10% of them are truly correct.
If someone tells you they’re allergic to penicillin, there’s a nine out of 10 chance that they are just not right. They’re not lying to you, they’re just confused. They’ve been given false information. And that’s a problem because, if you’re not sure whether something is safe to use in general, someone’s going to avoid using it just out of concern for patient safety, workflow, et cetera.
Our colleagues in allergy medicine, the Quad AI Society (American Academy of Allergy, Asthma & Immunology) have decided that enough is enough, and they’ve looked over a period of years at a number of trials, clinical evidence. It is pretty convincing to say that–generally speaking–if we talk to patients who have a penicillin allergy label, we can very rapidly identify those who truly are allergic and should not get cephalosporin, versus the majority who actually are completely 100% safe to have cefazolin perhaps in addition to vancomycin. The key here is to have the conversation: talk more, test less, use the best antibiotic possible.
Dr. Tom Callahan
See that’s really impactful because I can tell you it comes up very often, right? Where you talk to a patient, they report either a penicillin or usually penicillin, but sometimes a cephalosporine allergy and you pump the brakes, right? You stop. But, but in, in your heart of hearts, you know that you could probably use some of these medicines for some of these patients.
Dr. Paul Pottinger
That’s right. And you want to go into that case feeling like you’ve done your due diligence. You’ve given them the best preventative antibiotics based on the best information.
Dr. Bruce Wilkoff
And the data is better for cefazolin. Well, the data is better for cefazolin than any other antibiotic, including I remember some of the data from the WRAP-it study, but other studies as well that cefazolin patients had fewer infections than the Vanco patients. Although combined use may be the best of situations here, we just don’t have the data right now.
If it’s important to get the cefazolin in, what questions should we be asking? How do we go about doing that?
Dr. Paul Pottinger
Well, now there’s an app for that! We’ve built a web tool, to help make this a very quick conversation. The concept is that based on these structured questions, which come from the consensus statement from Quad AI, that within about a minute or so we can have reliable evidence-based recommendation for the electrophysiologist. Maybe we could do that right now.
Dr. Wilkoff, are you labeled with a penicillin allergy?
Dr. Bruce Wilkoff
I have that label on my chart.
Dr. Paul Pottinger
I have not been into your chart, but I can ask you some questions. So I have our app here and will link to this through the podcast.
PAL-ergy is your pal in the fight against bogus antibiotic allergies including penicillin allergy labels. So this is free, it’s open source. This is not for profit. And we’ll add a QR code and web link to the podcast. I’ve just clicked on that link here on my phone. Although it looks like an app, it’s actually just a website through the Red Cap system. I’m not even going to enter your name. We’re just going to go through the questions. Are you ready?
Dr. Bruce Wilkoff
Okay, I’m ready.
Dr. Paul Pottinger
All right, let’s do it. So here are the questions.
What allergy is this patient labeled with an allergy to? The antibiotic in particular.
Dr. Bruce Wilkoff
Penicillin
Dr. Paul Pottinger
Okay, so you think it’s penicillin. There we go. I’ll click on that. And so the next question is, what other penicillin allergies do you have? Is it only penicillin or are there other penicillins (amoxicillin, dicloxacillin), that you’ve been labeled to?
Dr. Bruce Wilkoff
As far as I know, when I was very small, I had, uh, got penicillin and I really don’t even know what kind it was, but maybe that’s all there was back then. It’s a long time ago.
Dr. Paul Pottinger
It’s interesting how little we now use penicillin, and yet these labels are common. Okay. Very good. That’s fine. Next: are you allergic to cephalosporins (cephalexin, cephaoxyl, cepha-anything)?
Dr. Bruce Wilkoff
I don’t know, because nobody’s given them to me.
Dr. Paul Pottinger
There you go. So we’ll click no known cephaolosporin allergy there. Here’s the next one: Since you were told you were allergic to penicillin, have you taken penicillin or amoxicillin or any other kind of cillin?
Dr. Bruce Wilkoff
Not to, not to my knowledge.
Dr. Paul Pottinger
Thank you very much. You’d be amazed how often that does happen. Next: do you remember what your allergy is? What happened when you took penicillin?
Dr. Bruce Wilkoff
I was an infant.
Dr. Paul Pottinger
Even with your amazing powers of recollection – I’m going to say that we do not know.
And then, the next question says: Does the medical record list an allergy that the patient denies? No. You truly believe that you are allergic to this based on what you’ve been told. Next: Do you recall whether you were seen by a medical doctor at that time? Probably don’t recall.
Dr. Bruce Wilkoff
I have no idea. They probably gave me a shot in my rear end, something like that.
Dr. Paul Pottinger
Maybe! So patient does not recall. And this was more than 10 years ago, is that when this happened?
Dr. Bruce Wilkoff
Yes. Much more.
Dr. Paul Pottinger
Yep. So what we have here, and I’m going to send a shot of this so that people can watch this as well, but we have a recommendation from PAL-ergy, and it’s in bold, it’s in yellow, and it’s pretty easy to read: It is okay to use a full dose of any cephalosporin, aztreonam, any carbapenem or any non-beta-lactam antibiotic. It is also okay to give penicillin after a test dose. So what this means is that if you were to come to the EP lab and we had someone who needed to operate on you, you would be very safe to get cefazolin. On the other hand, if on rare occasion you actually needed penicillin, we would give you an oral dose first in the clinic and have you flip on your phone or watch TV for an hour. And if you’re okay, then you’d be fine for full dose. So that’s how quickly we can go through this process.
And our vision for this, with respect to EP is that, if I’m not mistaken, usually you’ll know who this patient is before you operate on them. You should have a conversation pre-op, and whether that’s you, whether that’s one of your APPs, these questions are easy. It could be an MA, it could be an RN who does this, or a physician. It can be done pretty quickly, and my hope is that that can happen preoperatively.
Our vision that primary care does this routinely for every patient in America. The reality is that’s going to take a while. So, in the meantime, we want to get this out there, to all the surgeons and cardiologists who might need to have access to it. And again, it is free open source and I hope helpful.
Penicillin Allergy Assessment Tool
Dr. Bruce Wilkoff
Yeah, I think it could be revolutionary because, there are so many labels out there. You say 10%, but sometimes it seems like its 50%.
Dr. Paul Pottinger
At a center like this, it’s actually, well, at our hospital its closer to 20%. Okay. At large referral centers, the rates do exceed 10%.
Dr. Bruce Wilkoff
So, it’s so common and, and it’s such a useful and inexpensive antibiotic. I want to ask you another question about, about this though.
I think we mostly dose the medicine wrong too. So, I wonder, if we should get it out there. How should we be using the cefazolin?
Dr. Paul Pottinger
Cefazolin should be dosed based on patient body weight: for patients who weigh less than 120 kilograms, the dose is 2 grams of cefazolin. Ideally we should finish the infusion within 30 minutes of incision. If it has to be within an hour, that is acceptable, but the closer to the time of incision is right. However, if the patient weighs more than 120 kgs, we give a third gram, so it is actually 3 grams for those larger patients. This is similar to what we do for Vancomycin with respect to dosing based on body weight. We have not traditionally done this with cephalosporins, and that’s to the patient’s detriment. So we really do need to be thoughtful about that based on patient size.
Dr. Bruce Wilkoff
Right.
Dr. Tom Callahan
And how about postoperative antibiotics? I know there’s a little bit of debate out there. Any data that suggests that that’s useful or not helpful.
Dr. Paul Pottinger
Thanks. It’s a great and important question, and we have the answer, thanks to Dr. Wilkoff, to you colleagues here at Cleveland Clinic and nationally as well. That’s the PADDIT trial, which examined postoperative antibiotics versus usual care, meaning to continue versus to stop antibiotics at skin closure. And in that trial, we did not find a statistically significant difference between those two arms.
The suggestion: most patients do not require postoperative antibiotics. I would say there can be individual differences and I think if at the time of closure, at any point during the case there’s something about that patient that seems different, maybe there’s a smoldering infection preoperatively, et cetera, always fine to talk with ID about this, but generally speaking, when the skin closes, so too does the pharmacy and we’re done with antibiotics.
Dr. Bruce Wilkoff
Well, there are so many more things to talk about antibiotics. There’s irrigation of the pocket, there’s postoperative. We’ve talked about postoperative antibiotics, but, but second doses and such like that. But I think we’ve got a really core bit of information here about how to use cefazolin, however we are going to say it, how we’re going to use it, how we’re going to dose it, and how we can get it to more people.
And I really appreciate everybody coming together for this. Just a little glimpse into how we can also collaborate between infectious diseases and the electrophysiologist.
Dr. Paul Pottinger
Collaboration is key. ID welcomes that. And, in addition, if people are using the tool that we’ve used today, we would welcome it. It is free, it is open source, and it includes a feedback button at the bottom, there’s the ability for you to let us know your experience. If there are problems with it, we would love to know. We want to crowdsource this and make sure that it is useful in the hands of people who need it.
Dr. Tom Callahan
Excellent. Thanks so much for the time.
Dr. Paul Pottinger
My pleasure, and thank you so much for having me.
Learn more
Pallergy – the Penicillin Allergy Assessment Tool
